Waterloo Wellington Integrated Care Program Evidence-Based Wound Care

Arterial Leg Ulcer Clinical Pathway

0-7 Days Expected Outcomes Notes Most Responsible Physician(MRP)/Nurse Practitioner (NP)  Refer patient to ‘Care Connects’ if no responsible practitioner currently involved with patient identified/informed  Determine if MRP/NP is part of Family Health Team (FHT) or Community Health Centre (CHC) and consider additional supports available

Medical/surgical history and co-morbidity management Risk factors include:  Chronic renal disease considered within care plan  Smoking  Congestive heart failure  mellitus  Impaired liver function  Hyperlipidemia  Use of systemic steroids,  Hypertension immunosuppressive and chemotherapy  Coronary artery disease  >70 years of age  History of cerebral vascular accident  Age 50-69 years with history of diabetes (CVA) or smoking  Low hemoglobin  < 50 years with diabetes and one other  atherosclerotic factor  Poor nutrition  History of vascular surgery or deep vein  Decreased thyroid function thrombosis  Psoriasis  Bleeding disorders  Autoimmune diseases  Family history of arterial disease Medication reconciliation and their impact on  Prescription, non-prescription, naturopathic and illicit drug use (including e-cigarettes, reviewed inhaled substances and nicotine replacement therapy)  Medications that can affect healing include: chemotherapy, anticoagulants, antiplatelets, corticosteroids, vasoconstrictors, antihypertensives, diuretics and immunosepressive drugs  Other medications used to treat acute episodic illnesses may affect healing (eg. antibiotics, colchicine, anti-rheumatoid arthritics)  Vitamin and mineral supplementation

Recent blood work and diagnostic test results reviewed and  Determine bloodwork implications for wound healing considered  Blood Sugar, if patient is Diabetic  A1C, if patient is Diabetic  Albumin  CBC  Kidney Function  Colesterol level  Any diagnostic tests done previously i.e: Vascular Segmental Studies, UltraSound Doppler Waterloo Wellington Integrated Wound Care Program Arterial Pathway Feb 10 2107 1

Patient’s nutritional status optimized  Calculate Body Mass Index (BMI)  Determine recent weight loss/gain  Review blood work results  Complete Mini Nutritional Assessment (MNA)  If screening section results < 11 = complete assessment section  If Assessment section results < 24 = Registered Dietician referral required

Physical assessment performed  Baseline blood pressure, pulse and respiration  Baseline weight and height, BMI

Wound and periwound assessment completed Complete:  Measure and document size of wound using the following reliable tool: Arterial Wound Characteristics  Bates-Jensen Wound Assessment Tool (BWAT) OR  Leg Ulcer Measurement Tool (LUMT)  Determine wound etiology 4 P’s of Arterial Ulcers  Arterial ulcers are typically pale at base of wound, have ‘punched out’ appearance, are Pale wound base more painful than expected and have low to no exudate Punched-out appearance  Results of LLA and ABPI/TBPI  Assessment for Painful  NERDS – Any 3 or more of the following indicate HIGH superficial infection Parched (low to no exudate)  STONEES - Any 3 or more of the following indicate HIGH superficial infection in deep compartment (Require Urgent Medical Attention)  Obtain photos following best practice as per framework for individual organization policies and procedures. Suggest following publication as guideline: http://mydigitalpublication.com/publication/?i=206722

Pain management considered and initiated Complete:  Use 0 – 10 Numeric Pain Rating Scale Pain Red Flags Possible Infection

 Increase in pain level (new pain in patients with altered 0 1 2 3 4 5 6 7 8 9 10 sensation ) No Moderate Worst Pain Pain Possible Possible Arterial Involvement Pain  Pain on walking (caused by intermittent claudication)  Arterial pain is typically described as:  Pain with elevation of lower limbs  Pain with elevation of lower limbs, rest pain, nocturnal pain and pain on walking (caused  Rest pain by intermittent claudication)  Nocturnal pain  Identify and document type of pain 1. Neuropathic Pain (described as burning, stinging, shooting, stabbing or hyperesthesia – sensitivity to touch). Suggested pharmaceutical treatment: Second generation tricyclic agents – e.g. Nortriptyline or Desipramine. If pain is not relieved try using Gabapentin or Pregabalin. Waterloo Wellington Integrated Wound Care Program Arterial Pathway Feb 10 2107 2

2. Nociceptive Pain (described as sharp, aching or throbbing). Suggested pharmaceutical treatment: Non-Opioids – e.g. ASA or Acetaminophen Acute arterial occlusion is a life and limb-threatening situation Mild Opioids – e.g. Codeine which requires immediate emergency intervention especially if Strong Opioids – e.g. Morphine or Oxycodone there is sudden or severe pain  Obtain MRP/NP orders for pharmaceutical treatments (opioids and non-opioids)  Non-pharmacological pain control options

Lower Limb Assessment Completed Bilateral lower leg assessment (LLA)completed Complete:  Complete ABPI/TBPI Right ABPI/TBPI: Highest Right Ankle/Toe Pressure =  If ABPI/TBPI completed within last 3 mths, results must be obtained Highest Brachial ______ If unable to obtain ABPI/TBPI, referral to medical imaging for Vascular Segmental Studies is Left ABPI/TBPI: Highest Left Ankle/Toe Pressure = recommended Highest Brachial ______ Referral to Vascular Surgeon as soon as Vascular Segmental Studies result is available.  Repeat ABPI/TBPI assessment every 3 months if healing is not progressing Assess for Signs and symptoms of Peripheral Arterial  Assess pulses (popliteal – behind knee , dorsalis pedis – top of foot , posterior tibial – medial Disease (PAD): ankle)

 Pain with elevation of lower limbs, rest pain,

nocturnal pain and pain on walking (caused by intermittent claudication)  Dependent rubor in lower legs and feet  Pallor in feet on elevation  Dry, shiny skin on lower legs  Edema subsequent to leg being dependent  Thick or flaking toe nails  Hairless lower legs and feet  Weak or absent pulses

 Intense hyperesthesia (sensitive to light touch)  Limb muscle may appear wasted from ischemic atrophy  Delayed capillary refill  Distal gangrene  Non-healing wound

Correct Outcome Based Pathway Confirmed Wound etiology and appropriate pathway established  Confirm wound etiology  Arterial ulcers are typically pale at base of wound, have ‘punched out’ appearance, are more painful than expected and have low to no exudate  Results of LLA and ABPI/TBPI  Identify initial cause of wound Waterloo Wellington Integrated Wound Care Program Arterial Pathway Feb 10 2107 3

 Results of lower leg assessment (LLA)  Results of ABPI/TBPI  Results of wound assessment  Vascular Segmental Studies results If etiology is still unknown, referral is needed for wound Care lead or ET.

Referral For Vascular Assessment Initiated/Completed  Communication with MRP and/or Nurse Practioner to update on any significant changes in Peripheral Arterial Disease (PAD) (see guidelines for PAD) patient’s condition or the outcome of the assessment.  Referral to Vascular Surgeon as soon as Vascular Segmental Studies result is available.

ABPI 0.5 to 0.8 TBPI 0.64 to 0.7

Suggest Transcutaneous Oxygen Acute arterial occlusion is a life and limb-threatening situation which Pressure (TcPo2), Laser Doppler requires immediate emergency intervention Flowmetry, Doppler Arterial Waveforms or Segmental Doppler Pressure studies Signs and symptoms that may become severe may be associated with the following:  Pale or blue skin ABPI <0.5 TBPI <0.64  Skin cold to the touch Urgent vascular surgical consult needed  Sudden decrease in mobility  No pulse where one was present prior to this  Sudden and severe pain

Wound Therapy Initiated Wound treatment plan determined in accordance to treatment  Arrange for MRP/nurse practitioner orders as required to begin plan of care including goal (healable, maintenance or non-healable) agreeance to professional referral recommendations  Identify any potential barriers to wound treatment plan Caution: USE DRY WOUND HEALING  Utilize toolkit to determine wound cleansing, debridement and dressing selection 1. Keep eschar dry  South West Region Wound Care Program 2. No occlusive dressings  Wound Cleansing Table and Dressing Selection and Cleansing enablers 3. Do NOT debride  CAWC Product Picker chart 4. Avoid tourniquet effect when securing dressings CAUTION: When Using Compression 5. If eschar becomes wet/boggy – URGENT referral to

advanced wound care specialist is recommended Compression is typically contraindicated in the presence of peripheral arterial disease. In some

circumstances light compression may be beneficial, but only if arterial supply is sufficient.

Sufficient arterial supply should be objectively evidenced by diagnostic tests. In such cases, compression should be ordered by an advanced wound care physician or nurse practitioner only.

Compression therapy history documented:  Previous compression garments  Age of compression garments Waterloo Wellington Integrated Wound Care Program Arterial Pathway Feb 10 2107 4

 Adherence  Application and removal of compression in past  Finances  Reason compression treatment plan has changed if applicable

Patient Discharge Planning Initiated For Patient Independence And Prevention Patient and caregiver concerns and goals integrated into the care Complete: plan and shared with care team  Cardiff Wound Impact Questionnaire OR  World Health Organization Quality of Life (WHOQOL) form  Ensure all patient/caregiver goals and concerns been addressed

Patient counselled on the benefit of comfort measures  Personal assistance available to perform activities of daily living  Safety of transfers  Recommendations for exercise to decrease claudication if tolerated  Consider Occupational Therapist referral for comfort measures  Encourage patient to sleep in bed with no lower limb elevation (most arterial pain increases when feet elevated above heart level)  Mobility and dexterity aids currently being used

Coping strategies implemented into plan of care  Patient’s concerns and fears  Signs of anxiety or other mental health issues (eg. delusions, hallucinations, paranoid behaviour)  Depression screen using Geriatric Depression Scale assessment form –GDS15  Suicide assessment if applicable  ETOH and illicit /recreational drug use

Family and caregiver support identified and incorporated into plan  Family/caregiver actively able to participate in treatment plan of care

Social supports/communityresources currently utilized is  Family support integrated into plan of care  Community resources  Respite and Adult Day Program  Private insurance availability  Eligibility for Assistive Devices Program, ODSP, High-needs fund, Veterans Affairs Canada or Aborignal Services  Confirm that ongoing medication coverage is arranged Link to Trillium Drug Benefits http://www.health.gov.on.ca/en/public/programs/drugs/programs/odb/opdp_trillium.aspx

Professional referrals are initiated  Ensure referrals done according to patient’s needs  Refer to guideline for list of health care professionals Waterloo Wellington Integrated Wound Care Program Arterial Pathway Feb 10 2107 5

 Consider referrals to ET/Wound Care Lead if required to ensure appropriate treatment plan.

21-28 Days Expected Outcomes Notes

20 – 30% reduction in wound size Reassess, measure and document size of wound. Calculate the  Measure and document size of wound percentage of healing  Bates-Jensen Wound Assessment Tool (BWAT)  Complete BWAT score at each visit  Re-assess for infection at each visit (arterial are at high risk of infection)  NERDS – Any 3 or more of the following indicate HIGH superficial infection  STONEES - Any 3 or more of the following indicate HIGH superficial infection in deep compartment (Require Urgent Medical Attention)  Obtain photos following best practice as per framework for individual organization policies  Complete: Percentage of Healing (Cacluated from the initial visit)  Calculation: The two most important points are that measurements are done weekly, and using a standardized method within each organization.

V (Initial) – V (Current) x 100 = % reduction in volume V (Initial) (V = volume of wound calculated as Longest Length x Perpendicular Widest Width x Depth straight in) (Adapted from Sussman and Bates-Jensen 2007)

 Consider required referrals to ET/WCS/MRP/Surgeon/NP and further follow-up with previous professional referrals if healing percentage is not achieved  Wound Therapy Reassessed  Utilize toolkit to determine wound cleansing, debridement and dressing selection (South West Region Wound Care Program: Wound Cleansing Table and Dressing Selection and Cleansing enablers and CAWC Product Picker chart)  Review the Treatment Plan  Review pain level with elevation of lower limbs, rest pain, nocturnal pain and pain on walking (caused by intermittent claudication)  Review medical/surgical history and co-morbidity management for changes  Review medication for changes  Review recent blood work, diagnostic test results and home gylcaemic control  Review recent dietary consult if applicable  identify need for debridement (in presence of good arterial supply)

Chronic Disease Self- Management Plan Initiated Chronic Disease Management  Client and caregiver appropriate for self- management  Identify any potential barriers

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 Review adherence to the plan  Resources in place for self-management Patient/caregiver educational plan initiated Patient/caregiver educational plan initiated  Emergency signs and symptoms of Peripheral Arterial Disease (PAD) that require immediate Compression is typically contraindicated in the medical attention presence of peripheral arterial disease. In  Risks of compression therapy some circumstances light compression may be  Smoking cessation including e-cigarettes and nicotene replacement beneficial. In such cases, compression should  Glucose control therapies be ordered by an advanced wound care  Weight control physician or nurse practitioner only. See  Pain Management algorithm in guidelines.  Self management of wound care  Reduce risk of an infection  Diagnostic vascular testing  Vascular surgery: revascularization  Graduated walking program  Prevention of injury – avoid extremes (hot/cold, caffine, loose/tight garments)  When to call primary care giver (eg. signs and symptoms of infection, deep vein thrombosis, cellulitis, impaired blood flow)  Limb preservation  Community support groups Ability to self-manage optimized  Barriers to participate in self care transportation, socioeconomic, social environment, other co-morbidities)  Cognitive ability to self manage care  Review importance and potential barriers to smoking cessation at every visit  Hygeine to prevent  Environment  Wound care  Compression application and removal if prescribed  Daily exercise 77-84 Days Expected Outcomes Notes Wound is closed by 12 weeks  Ensure wound is closed.  Encourage client to control factors that lead to arterial disease  Smoking cessation  Blood pressure regulated  Cholesteral controlled  Report any signs and symptoms of leg/foot pain to physican/NP/vascular surgeon  Promote exercise and diet If wound is not closed, move to most appropraite pathway i.e: Maintenance Pathway or Non- healing Pathway

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